Office manual for health care professionals - Aetna

1 quality health plans & benefitsHealthier livingFinancial well-beingIntelligent solutionsOffice manual for health care D (7/16) to Aetna s Office manual for participating physicians, facilities and Office staff. 2 Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies ( Aetna ).Key national contacts 5 Behavioral health 7 Electronic solutions 8 Medicare 10 Member programs/resources 21 Member rights and responsibilities 23 Office management 29 Patient management and acute care 37 Performance programs 42 Pharmacy management 44 Policies 47 Women s health 50 You ve told us what s important to you.

2 As a result, we developed this manual to help you navigate the often challenging world of health care . Whether you re new to Aetna or have participated with us for years, we believe you ll find the Office manual helpful in your day-to-day work. It contains meaningful information that makes it easier for you to work with us more effectively and efficiently. Topics range from how to get claims paid faster to learning how to reduce administrative burdens. We designed the Office manual to give you more time to focus on what s most important to you improving the health and well-being of your patients. If you re new to Aetna s networkWe have tools and resources to introduce you to working with Aetna .

3 These include: Aetna at a Glance: This quick reference guide will help you learn about various tools and transactions. It also contains important contact information. Go to and select Reference Tools. Aetna Benefits Products booklet: This easy-to-use handbook contains information on Aetna benefits products, including primary care physician (PCP) selection, referral requirements and precertification instructions. To find it, visit and select Reference Tools. Local network informationRegulations and Aetna program requirements may vary from state to state, so the regional information section includes some market-specific information. The key national contacts and regional information sections provide access to important contacts, including website addresses and telephone and fax you need to knowWe also recommend you learn more about the following topics: Secure provider website: You ll notice the term secure provider website used throughout the Office manual .

4 You can perform most electronic transactions through this website. That includes submitting claims, checking patient benefits and eligibility, and requesting precertifications. You have to register to use the website. Patient advocacy: As advocates on behalf of your patients who are Aetna plan members, you should review and become familiar with the member rights and responsibilities outlined in the Office manual . Informed consent: You re responsible for providing your patients with all the information relevant to their conditions. This includes all health care alternatives, including potential risks and benefits, even if their plan doesn t cover the option. Patient emergencies: If your Aetna patients need emergency care , they have coverage 24 hours a day, 7 days a week, anywhere in the world.

5 Providing information: By providing us with complete and accurate medical information and diagnoses, you help us make appropriate coverage determinations. Independent contractors: As indicated in our physician agreements, participating health care professionals are not employees or agents of Aetna or any of our affiliates. Guidance on coverage: If you re unsure whether a particular service or treatment is considered medically necessary or experimental/investigational under a patient s plan, consult our Clinical Policy Bulletins. Appeals: You can appeal adverse benefits determinations and physician or other health care professional adverse reimbursement decisions.

6 Members may have the right to an external review if the circumstances of the appeal meet the criteria for external review. Medicare appeals will follow the guidelines set by the Centers for Medicare & Medicaid Services (CMS). Products: We use the following product groupings throughout the Office manual to simplify references to the variety of benefits plans. (Not all products are available in all areas.) 3 Note: The term precertification (used here and throughout the Office manual ) means the utilization review process to determine if a requested service, procedure, prescription drug or medical device meets our clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO selection and referral required with some direct access optionsAetna MedicareSM Plan (HMO) (available in select markets) Aetna SelectSMElect Choice (EPO)HMOPCP selection and referral not required, except to receive maximum benefitsManaged Choice POSQ uality Point-of-Service (QPOS )PCP selection encouraged, but not required (open access features)

7 * Aetna Choice POSA etna Choice POS IIAetna health Network OptionSMAetna HealthFund health Reimbursement ArrangementAetna HealthFund health Savings AccountAetna Limited Benefits Insurance Plan (PPO)** Aetna MedicareSM Plan (Open Access HMO) available in select marketsAetna MedicareSM Plan (PPO) Aetna Open Access Elect ChoiceAetna Open Access HMOA etna Open Access Managed Choice Aetna Voluntary Group Medical Plan (indemnity)**Open Access Aetna SelectSMOpen Choice PPOT raditional Choice **Except for behavioral health or based on plan sponsor requirements.**Formerly Aetna Affordable Contact informationProvider servicesHMO-based and Medicare Advantage plans 1-800-624-0756 Aetna LeapSM plans and all other plans 1-888-MD- Aetna (1-888-632-3862)Patient management/precertificationHMO-based and Medicare Advantage plans 1-800-624-0756 Select Precertification from the other plans 1-888-MD- Aetna (1-888-632-3862) Select Precertification from the expedited organization determinations (EODs)Fax: 860-754-5468 Note: Use this fax number only for Medicare EODs.

8 For non-expedited requests and all requests for Part B medical injectable items, continue using your current management precertification Pharmacy management precertification Phone: 1-800-414-2386 Fax: 1-800-408-2386 Specialty drug precertification Phone: 1-866-503-0857 Fax: 1-888-267-3277 OnlineAetna Specialty Pharmacy (for ordering self-injectable medications)Phone: 1-866-782-2779 OnlineAetna health ConnectionsSM disease management program1-866-269-4500 Beginning Right maternity program1-800-272-3531 Breast cancer case management program1-888-322-8742 BRCA genetic testing program (genetic testing for breast and ovarian cancers)1-877-794-8720 Infertility program1-800-575-5999 National Medical Excellence Program (transplants)

9 1-877-212-8811 Informed health Line1-800-556-1555 Behavioral Health1-888-632-3862 Medicare Service Center1-800-624-0756 Aetna Workers Comp Access service center1-800-238-6288 Aetna Student HealthPO Box 15708 B o ston, M A 02 215- 0 014 Key national contacts5 Dispute submissionWrite to the PO box listed on the Explanation of Benefits (EOB) and/or the denial letter related to the issue you re disputing. Include the reason(s) for the disagreement. HMO-based and Medicare Advantage plans: 1-800-624-0756 All other plans: 1-888-MD- Aetna (1-888-632-3862) Note: Callers should have the EOB and the original claim for electronic payer ID number60054 Website LinkAetna s secure provider Tr i a g e website online referral s medication search tool (formulary) Women s HealthSM programhttp: Workers Comp Compassionate CareSM for Affordable quality Healthcare (CAQH ) s education site for health care healthCheck out information on the Behavioral health page at There you ll find.

10 Our comprehensive Behavioral health Provider manual Archived issues of our Aetna Behavioral health Insights newsletter for participating behavioral health professionals Aetna Behavioral health Programs overview Utilization Management how we determine coverage Our behavioral health clinical practice guidelines can be found on page 39 of this manual , on page 9 of our Behavioral health Provider manual , or on our secure provider solutionsOverviewElectronic solutions for provider offices and facilities From the time an Aetna member schedules an appointment through claims payment, we re committed to making it easy for your Office or practice to work with us electronically.